July 23, 2013
What is the link between post-traumatic stress disorder and pregnancy? Do obstetricians have an obligation to screen patients for histories of trauma?
Dr. Amina White, OB/GYN at Howard University in Washington, DC, has recently completed a Master's thesis for the Georgetown School of Continuing Studies on trauma-informed care, which provides an ethical justification for changes to the obstetrical treatment of trauma survivors. KIE Director Maggie Little served as her advisor.
After Dr. White graduated from Harvard Medical School, she completed her OB/GYN residency training at Georgetown University Hospital and then joined the faculty at the Howard University College of Medicine. Her clinical training is in Obstetrics and Gynecology. Through an Intramural Research Training Award from the National Institutes of Health (NIH), she has begun a 2-year postdoctoral fellowship in the NIH Department of Bioethics. As a fellow, one of her current projects involves exploring the obligations of clinicians to meet the needs of trauma survivors—an approach called trauma-informed care.
What drew you to the issue of trauma informed care?
During my residency, I encountered ethical dilemmas involving patients, families, and medical decision-making that awakened my interest in bioethics. I recognized my need to better understand the principles of medical ethics in my own practice and for the purpose of teaching medical students and residents how to approach such dilemmas.
In my clinical practice, I have encountered many patients with a history of sexual assault or abuse. I was aware that approximately 1 in 5 women have experienced attempted or completed sexual assault at some point in their lives.
However, it was not until I learned in an ethics course about the debilitating effects of traumatic events and chronic post-traumatic stress symptoms on an individual's sense of identity, bodily integrity, and autonomy that I realized the implications for obstetrical care.
Meeting the needs of trauma survivors during their pregnancies requires sensitivity to subtle triggers, which may arise from bodily sensations like fetal movement or from procedures that obstetrical caregivers routinely perform. Childbirth itself can awaken memories of past trauma and lead to post-traumatic stress reactions for some trauma survivors.
Describe your research.
My current research focuses mostly on improving the process of screening women for a history of trauma, something that is already part of a normal prenatal care intake visit. It can be challenging for clinicians to ask sensitive questions about and know how to best respond to a woman's trauma history disclosure, especially when it involves childhood abuse.
In our recent focus group study done in collaboration with the National Center for Trauma-Informed Care, we invited trauma survivors to share their perspectives on helpful and unhelpful physician approaches to inquiring about a woman's trauma history during prenatal care. It's important to note that most trauma survivors do not have chronic post-traumatic stress symptoms. Screening is therefore aimed at identifying those with chronic symptoms who may have lower resilience, which is the capacity for adaptive stress coping.
Since childbirth can represent a re-traumatizing event and recent data suggest that nearly 1 in 12 pregnant women in the U.S. are suffering from chronic post-traumatic stress during pregnancy, obstetricians have a critical role to play in trauma screening, mental health referral, and resilience-focused delivery preparation for those with chronic symptoms. Consistent and sensitive trauma screening in prenatal care is the first step to improving the care for this population during pregnancy.
Why are you focusing on its place in obstetrics, and not in psychiatry?
Post-traumatic stress disorder (PTSD) is a psychiatric condition, but it also appears to have specific implications in pregnancy. There is strong evidence that PTSD is associated with adverse maternal health outcomes related to major depression, substance abuse as a form of stress coping, and self-harming behavior that can directly impact maternal well-being and lead to pregnancy complications. Although more research is necessary to better understand fetal and neonatal effects, some studies have shown that it may be a predictor of low birth weight and preterm delivery.
Since an obstetrician may be the first healthcare provider to encounter a woman with undiagnosed post-traumatic stress symptoms during pregnancy, it is critical for the obstetrician to be able to identify and refer those patients who could benefit from psychiatric evaluation and symptom management. But it is also important for the obstetrician to avoid causing further harm by triggering post-traumatic stress reactions during the course of routine care.
What kinds of practices would you recommend for those working in prenatal/obstetric care?
There are certain practices that obstetric care providers should observe at every clinical encounter, regardless of whether or not a woman has a trauma history. Examples of such practices include asking permission before touching a patient, maintaining privacy, avoiding unnecessary exposure during sensitive parts of the physical exam, and ceasing further examination if a patient shows signs of distress. If a woman does report a trauma history, I recommend a 3-step approach to meeting trauma-related needs.
First, it is important to screen for PTSD since a trauma history alone does not necessarily mean that a woman has chronic stress symptoms. There are many brief screening tools that can be used for this purpose. Second, those patients with chronic symptoms who screen positive for PTSD should be referred to a mental health provider for further evaluation and symptom management.
Third, I recommend that obstetric care providers generate a trauma-informed obstetrical care plan for avoiding specific post-traumatic stress triggers and for preparing the woman to cope with certain unavoidable triggers that are likely to arise in the course of routine prenatal care and delivery. Trauma survivors may especially benefit from resilience-focused childbirth preparation in the form of a flexible birth plan and arrangements for a doula, or labor coach, to be present in the delivery room.
What's next for this research?
Much more research needs to be done to identify the most effective interventions for pregnant women who have a history of childhood sexual abuse, which appears to have more damaging long-term effects than other forms of trauma.
There is also a need for health disparities research on trauma-informed interventions. The prevalence of PTSD in pregnancy is four-times higher among African American women than for non-African American women. I am therefore planning a study of peer support as a resilience-enhancing intervention for childhood trauma survivors in a low-income prenatal care clinic that serves primarily minority patients. We hope to begin the project this fall.
Disclaimer: The views expressed in this interview are those of Amina White and do not represent the views or policies of the National Institutes of Health or the Department of Health and Human Services.